Health Care Expenditures and Health Care Quality in Maine: Baseline Report

Public Law 2021, Chapter 459 (LD 120), An Act To Lower Health Care Costs through the Establishment of the Office of Affordable Health Care, created the Office of Affordable Health Care. The Office of Affordable Health Care is established as an independent executive agency for the purpose of analyzing health care costs in the State of Maine in accordance with the duties described in §3122(3), which includes the following: at a minimum, the office shall use data available from the Maine Health Data Organization (MHDO), established pursuant to Title 22, chapter 1683, and the Maine Quality Forum (MQF), established in Title 24-A, section 6951.

At the request of the Governor’s Office, the MHDO produced a report on health care expenditures and health care quality in Maine to serve as a baseline to begin to inform the discussion on health care payments and health care quality in Maine. The first section of the report is focused on health care expenditures/payments with has been developed into an interactive Tableau Report. The interactive Tableau Report provides access to a multitude of selection criteria displaying thousands of data points. MHDO produced this baseline report in a way that can be easily refreshed and, if requested, used to expand into additional reports in the future, such as payer-level and provider-level analyses. The Interactive Tableau Report is below along with helpful tips.

Data Source and Methodology

The data used to develop the baseline report is the All-Payor Claims Data (APCD) that payors submit to the Maine Health Data Organization per the requirements in Rule 90-590, Chapter 243, Uniform Reporting System for Health Care Claims Data Sets. Additional information about the APCD including how many individuals are represented as part of this analysis, is found on the MHDO Available Data page.

Lastly, the baseline report was largely informed by the Recommended Standard Analytic Reports: Phase 1 of A Data Use Strategy for State Action to Address Health Care Cost Growth Report (Peterson-Milbank); a few data points are informed by the Massachusetts Health Policy Commission. Additionally, the Maine Quality Forum provided baseline information specific to the status of reporting and measuring the quality of health care in the state of Maine and nationally.

Detailed information on the definition of payments and the measures developed for this report is here Appendix A, Methodological Notes.

Highlights of Baseline Report

Most of the highlights below are focused on the dashboard tab labeled "Overall," which is one of six interactive displays of the data, referred to as report “pages.” To further understand what is driving the changes observed in the overall payments, users can explore the detailed breakdowns available in the report, by drilling down on geography (based on the location of residence of the insurance enrollees), demographic groups, and by groups of individuals with selected chronic conditions, such as diabetes, Alzheimer’s disease, hypertension, cancer.

  • Total payments for commercial plans have increased every year, except in 2020, (Overall page, Payment Amounts display) with the largest year-over-year (YOY) increase of 10.8% occurring from 2020 to 2021 (Overall page, Year-Over-Year Percent Change display). Some of this increase may be compensating for the decrease observed for the period 2019 to 2020, likely attributable to the decrease in the use of medical services during the initial peak of the COVID-19 pandemic.
  • Total payments have been increasing annually every year from 2018 through 2021 for MaineCare and Medicare Advantage plans, across all service types combined (Overall page, Payment Amounts display), but per capita payments have decreased when comparing 2017 to 2021 – MaineCare went from $13,451 to $11,992 and Medicare Advantage went from $14,749 to $13,060. The observed MaineCare trend aligns with a national trend of enrollment growth due to continuous coverage requirements associated with the COVID-19 Public Health Emergency: members who would have normally been disenrolled due to loss of eligibility have maintained coverage (Per Capita Payments denominator). These members tend to have lower healthcare utilization (Per Capita Payments numerator).
  • For Medicare, total payments and per capita payments have varied (Overall page, Payment Amounts display and the Year-Over-Year Percent Change display).
  • Of the 30 Chronic Conditions, the total payments for individuals with Depression, Bipolar, or other Depressive Mood Disorders were the highest among the other chronic conditions for those with MaineCare coverage, while total payments for individuals with Hypertension were highest among the other chronic conditions for those with Commercial, Medicare or Medicare Advantage coverage, for each year included in this analysis (Chronic Conditions page, Payment Amounts display).
  • The top 25 costliest drugs are all brand name drugs, with a total cost of $757,322,271 — with Medicare Advantage paying over half of those costs at $401,992,957. For the top 25 costliest generic drugs, the cost is $44,823,272, with Medicare Advantage paying over half at $28,581,421 (Rx Drug Spending page, top 25 Costliest Drugs display).
  • In 2021, for all payers combined, total payments made by service category were ranked from highest amounts to lowest as follows: Professional (26.4%), Pharmacy (24.5%), Hospital Outpatient – institutional portion only (19.7%), other institutional services (17.5%), Hospital Inpatient – institutional portion only (16.0%). For commercial insurance, the largest percentage of payments were for Hospital Outpatient services – institutional portion only (29.4%); for MaineCare, the largest percentage was for Professional (40.0%); for Medicare, the largest percentage was for Pharmacy (23.0%); and for Medicare Advantage, the largest percentage was for Pharmacy (26.5%). As noted above, payments for MaineCare in this baseline report are reflective of services that are traditionally not covered by commercial or Medicare insurance.

Important Notes:

Given the data source and methodology used for this baseline report, it is important to note the following:

  1. At the time of producing this baseline report, non-claims-based payments were not available, that is payments that are for something other than a fee-for-service claim. These non-claims-based payments include, but are not limited to, Capitation Payments, Care Management/Care Coordination/Population Health Payments, Electronic Health Records/Health Information Technology Infrastructure/Other Data Analytics Payments, Global Budget Payments, Patient-centered Medical Home Payments, Pay-for-performance Payments, Pay-for-reporting Payments, Primary Care and Behavioral Health Integration Payments, Prospective Case Rate Payments, Prospective Episode-based Payments, Provider Salary Payments, Retrospective/Prospective Incentive Payments, Risk-based Payments, Shared-risk Recoupments, Shared-savings Distributions.
    Other non-claims-based payments that were not available for inclusion in the report are pharmacy rebate amounts.
  2. Payments for MaineCare include services that are traditionally not covered by commercial or Medicare insurance, specifically services covered in the following Long-Term Care Services (LTSS) policy sections:
    • Section 2 - Adult Family Care Services,
    • Section 12 - Consumer Directed Attendant Services,
    • Section 18 - Home and Community-Based Services (HCBS) for Adults with Brain Injury,
    • Section 19 - Home and Community Benefits (HCBS) for the Elderly and Adults with Disabilities,
    • Section 20 - Home and Community Based Services (HCBS) for Adults with Other Related Conditions,
    • Section 21 - Home and Community Benefits (HCBS) for Members with Intellectual Disabilities or Autism Spectrum Disorder,
    • Section 26 - Day Health Services,
    • Section 29 - Support Services for Adults with Intellectual Disabilities or Autism Spectrum Disorder,
    • Section 40 - Home Health Services,
    • Section 50 - ICF-MR Services,
    • Section 67 - Nursing Facility Services,
    • Section 96 - Private Duty Nursing and Personal Care Services,
    • Section 97 - Private Non-Medical Institution Services (PNMI) Appendix C and F,
    • Section 102 - Rehabilitative Services.
    The majority of these MaineCare payments are expected to be represented in the ‘Institutional: Other’ and ‘Professional’ service categories available as breakdowns in the report.
  3. The claim-based payments in this baseline report are calculated without any adjustments; they are not adjusted for inflation in healthcare costs, and not adjusted to control for differences in age, gender, or illness burden between groups.

How to Use the Interactive Report

  1. Use the navigation tabs on the left to select a page to view –
  2. except for the last two, all have payer type and service category breakdowns:
    • Overall – payment types displayed by payer type and service category
    • Member Liability – total payments and member liability by payer type and service category
    • Demographics – summary statistics by age group, gender
    • Geography – summary statistics by Maine county, market rating area, public health district
    • Chronic Conditions – summary statistics for groups of individuals diagnosed with selected chronic conditions
    • RX Drug Spending – top 25 prescription drug costs and utilization in Maine at retail at mail order pharmacies
    • Methodology – details on the methodology used to develop this report
    • Observations – notes about specific statistics displayed in the report
  3. Click on the Filter button () to expand a set of criteria such as payer type, measure, service category, and year – and use the drop downs to automatically adjust the information displayed on the respective report page.

The interactive dashboard below provides access to a multitude of selection criteria displaying thousands of data points.



© Maine Health Data Organization 2013